197608982-2-23-2024-29-AS-VCOY-D2QSUG-20240223131108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608982
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:11:21 PM

Document Has Been Signed on 02/23/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Arlene Ceballos		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Valeria Conway and Kelly Dullek arrived at the facility at 9:10AM unannounced to conduct a required Annual visit. The last annual conducted at this facility was on 12/21/2022. The LPAs met with Staff to explain the reason for the visit. Administrator Arlene Ceballos and Izhak Illouz arrived at the facility shortly thereafter. The LPA’s toured the physical plant areas inside and outside, with Administrator Izhak Illouz at 9:40 A.M., to ensure there are no health and safety hazards. Last Emergency Drill (Fire and Earthquake) was done on 01/08/24. BEDROOMS: There are (6) six bedrooms designated for resident use, all resident bedrooms are private rooms and (1) one bedroom designated for staff use. Bedroom #3 and Bedroom #4 have a direct exit to the exterior. Bedroom #4 and #5 has a Jack and Jill bathroom. The facility has furnished each room with clean linens, nightstands, lamps, chests of drawers, chairs and closet space, and sufficient lighting for resident use. The bedrooms were large enough to allow for easy passage. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. There are (4) four total bathrooms at the home. (2) Two are private bathrooms in Room #2 and #3. Restroom hot water measured 115.5 degrees Fahrenheit at 10:05 A.M. Continue on LIC 809C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 02/23/2024

NARRATIVE

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Continued from LIC 809

KITCHEN: Appliances in the kitchen were clean and all appeared functional. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored in a locked cabinet and inaccessible in the kitchen as well as medications and chemicals. Appliances in the kitchen were clean and all appeared functional. Laundry and house cleaning supplies are stored in a locked cabinet under the kitchen sink and inside the outside garage.

FILES: During today’s visit, the LPAs observed full bed rails on the bed of Resident #2. The Administrator stated that resident in room #2 is receiving hospice care services at the time of the visit. The Administrator provided bed-rail order. Staff file review revealed that Staff #1 (S1) and Staff #2 (S2) didn’t have health screening LIC503 nor TB Test negative results.

COMMON SPACES: The common spaces included the living room and dining area. The LPAs observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. Smoke detector(s) and carbon monoxide detector were tested at 9:55 A.M. and operational at the time of the visit, they are hardwired and interconnected. The fire extinguishers were observed to be in compliance and last charged on 02/16/2024. The LPA's observed required postings on the wall leading to the kitchen. At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a working telephone on premises. Auditory alarms were functioning at the time of the visit. An adequate supply of emergency food and water was observed at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. The facility has one (2) side gates that self-latches. No bodies of water noted at the time of the visit.

Continued from LIC 809C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 02/23/2024

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Continued from 809C

GARAGE: Is detached from the house and locked at all times. There is a freezer and a fridge full of extra food in it. LPA’s saw emergency water accessible laundry supplies, disinfectant, cleaning supplies and facility has a sufficient amount of Personal Protective Equipment (PPE)

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file record review, the licensee did not comply with the section cited above in 2 out of 5 staff members did not have their TB testing and Health Screening which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Provide documentation showing negative TB Test, and completed Health Screening for both staff members by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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